In exchange for decades of intellectual labor, sacrificed holidays, and a staggering burden of stress, physicians earn the sacred opportunity to serve those in the most dire need. Resolving not just physiological impairment, but the broader emotional and spiritual disturbances that trail illness, physicians are granted the privilege of restoring personal balance in one’s life.
Unfortunately, the reality is that the quality of treatment a physician delivers is not solely dependent on his or her expertise. Studies demonstrate that it is also dependent on the patient’s skin color, which will indirectly influence the treatment delivered and the health outcome.
To understand why, it is important to first recognize the data. Research shows that black Americans are 2 times more likely than white Americans to die of heart disease and stroke. They face higher rates of cancer, diabetes, HIV/AIDS, and pneumonia. The obesity rate for black women is double the obesity rate amongst white women. The death rate from asthma for black children is 500% higher than it is for white children. In addition, black men are two times more likely than white men to die of prostate cancer.
These health inequities, to name a few, can be credited to an array of factors, including poverty, education, nutrition, lack of health insurance, and cultural barriers, each of which share a dynamic interaction to preserve these disparities. However, one of these factors – the lack of black physicians in the medical field – is the product of systemic racial disparities, and if addressed, can guide the resolution of these inequities in the right direction.
The Need for More Black Physicians
While black Americans make up 13% of the US population, they constitute a meager 4.4% of Physicians, and are thus recognized as an underrepresented minority in medicine.
A fundamental component of the treatment process is the physician-patient relationship. This entity is built on trust, and is the very medium by which data is gathered, diagnoses are made, compliance is acquired, and satisfaction is delivered. If influenced by a physician’s negative implicit biases – feelings and beliefs outside of conscious awareness – or a patient’s reluctance to communicate, the treatment delivered may not be optimal. Ultimately, the color of one’s skin will indirectly influence the strength of this relationship.
Among the black community is a permeating distrust of the medical establishment. With a history of inequitable health care practices and events like the 1932 Tuskegee Syphilis Study, black patients oftentimes share an expectation for discrimination by physicians. They report a lower quality Physician-Patient Relationship, attributed partially to racial differences or language and cultural barriers with their providers. More specifically, black patients have been documented to prefer black physicians, rating such doctors as providing better interpersonal care than other-race physicians. With the shortage of black physicians, these patients rarely experience the physician-patient relationship they are most comfortable with. For many, this could result in a natural reluctance to express health concerns, and if information is omitted, the treatment quality will suffer. In terms of physicians, Hall et al. conducted a systematic review in 2015 suggesting that implicit bias against Black, Hispanic/Latino, Latina, and dark skinned individuals is present among many health care providers of different specialties, levels of training, and levels of experience, being particularly activated under stressful working conditions. For the selected sample, it was found that most providers had underlying positive attitudes towards white patients and negative attitudes towards people of color. These aspects can inadvertently compromise the delivered treatment, contributing to the existing health care disparities.
Studies have demonstrated that when patients share the same race or ethnicity as their physician, there is potential for improved health outcomes. Not only are patients more trusting of their physician, resulting in improved communication and medication adherence, but the provider will naturally be influenced by fewer implicit biases. In one randomized clinical trial, researchers recruited 1,300 black men and assigned them to a black doctor or a non-black doctor, examining the effect of physician workforce diversity on the demand for preventative care by the black patients. Prior to the consultation, patients were provided the opportunity to select preventive cardiovascular screenings and immunizations. These included body mass index (BMI) measurement, blood pressure measurement, diabetes screening, cholesterol screening, and a flu shot. The physicians were to inform those who did not elect for every test about the benefits of the preventative services, allowing them to opt for more screenings. The data analysis revealed that the patients selected a similar number of preventative tests in advance of their appointment. However, upon having their physicians discuss the benefits of the preventative cardiovascular examinations, the men who were assigned to black doctors (sharing the same race as their physician) were much more likely to select every preventive service – in fact, the patients assigned to black doctors increased their uptake of diabetes and cholesterol screenings by 49% and 71%, respectively. As described by the study, these two tests take more time than other tests and are relatively “invasive,” requiring more trust in the physician providing the service. A second finding of the investigation was that the men were more likely to express their health problems and seek advice from black doctors, as reflected in the doctors’ notes. These results were consistent with better patient-doctor communication2 when the physician shared the same race as the patient. Interestingly, the study involved a calculation revealing that black doctors could reduce the black-white male gap in cardiovascular mortality by 19%.
The strength of the physician-patient relationship is influential on the quality and completeness of information elicited and understood.4 That said, with more black physicians, this entity can be strengthened by increasing the degree of communication that takes place. Ultimately, this will secure a foundation for vulnerability and open expression, both of which are paramount to the delivery of effective treatment.
Furthermore, studies show that African American, Hispanic, and immigrant physicians are more likely to serve in under-served areas and support uninsured patients as well as those on medicaid. They are also more likely to enter specialties with national shortages, such as pediatrics and primary care.
In other words, if this shortage is resolved, three things may happen. Firstly, the Black Physician-Patient relationship will be fortified, potentially improving health outcomes. Secondly, the national health care system will be more equipped to serve the under-served and to advance pediatrics and primary care. Thirdly, there will be a cultural shift: black communities may become more trusting of the medical establishment. This will ease their recruitment in biomedical research and leave them more likely to pursue life sustaining technology and health care overall. In other words, addressing the shortage will address this public health crisis in a multi-factorial fashion. However, there are a number of hurdles that challenge black individuals from pursuing medicine.
Wealth, or the cumulative worth of a family’s assets, functions as an economic vehicle to uplift, and mobilize, a family’s future generations towards greater success over time. Wealth serves as a stepping stone, shaping the quality of education experienced, the richness and volume of opportunities available, and the health status, and ultimately performance, of an individual. In other words, the wealth of a family influences the cascade of experiences that will compound in accordance with each other during one’s development. Throughout American history, this vehicle has not been as readily available to the black population as it has to others.
The era of slavery deprived black Americans of social and economic freedom, diminishing black individuals from acquiring wealth. Their starting position in American history left them unable to build and pass on wealth to early generations. The Jim Crow Era stained America with the segregation of public schools and facilities, subjecting black Americans to a lower quality education and directly impeding their capacity to earn the same success as their white counterparts. Racism has inhibited their ability to pursue the same american dream that other populations have experienced. While white Americans have traditionally used wealth as a mechanism for economic mobility, black Americans are struggling to catch up and are disadvantaged by past and present systems in place.
With objectively less wealth than white Americans, higher unemployment, less stable jobs, and a lower average income, black children are more likely to be raised in lower income communities. The consequence of this is an ever present financial constraint, as well as an environment that fails to incubate a high quality educational experience. Black students are provided lower quality instruction, have less accessibility to resources, and are less likely to find influential mentors that can provide positive guidance. This academic setting fails to instill the habits and attributes that are needed to achieve success. For those who persist, the prospect of a college education comes with substantially more debt1 than it does for white Americans, yielding a lower likelihood to attend, or graduate from college. In fact, one study from 2018 demonstrates that blacks students held as much as 85.8% more debt than white students.6 Unlike young white adults, who are more likely to have their parents’ financial resources to shield them from debt, black youths are less likely to be protected by their parents’ wealth. Without that financial safety net, black students are often hesitant to pursue continued financial risk and post-secondary education. Ultimately, this circumstance positions black Americans into lower paying, less stable jobs for another generation. That said, there is a cyclical relationship between the financial and educational barriers that black Americans face: the financial constraints bring rise to a lower quality education, and the lower quality education conceives continued financial constraints.
With the interplay that both these factors have on the lives of black youths, the reasoning as to why there are fewer black physicians in the medical field comes to light. As examined by one study identifying black student perspectives on the pursuit of a medical career, it was found that the cost of education for college and medical school was so daunting that students were left disinterested in medicine. With existing financial challenges, the idea of taking on hefty loans left students overwhelmed. Complementing this was the fact that their education and background left them with limited opportunities and exposure to medicine. Very few students knew black physicians personally – not surprising, given the low quantity of black physicians in the field – and thus lacked a mentor, or role model to follow. Black students have also cited a lack of encouragement at home and in schools: for many, professional planning and career discussions were minimal (or nonexistent) at home and in school, and at times, counselors had been noted to directly advise students against pursuing medicine. This financial fear, ignorance, and a lack of support was, and still is, holding students back from pursuing medicine.
The same study also provides insight on cultural elements that gravitate students away from medicine. Among the students, there was a general consensus that physicians were typically both white and male. The students stated that they were fearful of pursuing medicine as they’d be socially ostracized for “acting white.” Alongside this negative peer pressure was a general fear of racism in the medical field and healthcare institutions. The students were fearful that they’d face racist remarks from their white physicians and patients, ultimately encountering rejection from both their black peers and their white counterparts. This fear of exclusion and racism creates a great deal of social pressure and contributes to the disinterest that many of these students demonstrate towards medicine.
Research Based Solutions
The same investigation provided potential solutions to address these challenges. To counter the lack of black physician role models, mentorship programs in inner city schools can provide shadowing experience and medical exposure, encouraging black students to consider medicine as a career. To counter the lack of emphasis on the importance of scholastic achievement in many urban schools, increased opportunities for academic enrichment and guidance in the form of career oriented discussions can bolster self confidence and motivation, promoting interest in medicine.8 The latter may also counter the negative peer pressure that ostracizes those who strive for academic excellence and are accused of “acting white” by encouraging student bodies to collectively pursue intellectually challenging work. These two solutions can positively shape the attitudes that students have at home and in school about becoming physicians, cementing a supportive, encouraging culture that fuels students with professional ambition.
The health inequities plaguing the black community are products of a multidimensional system that deserves attention at every angle. One component of this system – the lack of black physicians in the medical field – can be addressed if attention and commitment is devoted towards resolving the challenges facing black communities and students. Increasing this population of physicians will not only reduce the racial disparity, but will also positively impact public health profoundly. The physician-patient relationship will be bolstered for people of color in response to cultural similarities, increased empathy, and the newfound ability to identify with physicians. Patients will dive deeply into their concerns and perspectives on health, and over time, will become more trusting of healthcare institutions.
Black Americans have endured a dark history of oppression that systemically endorsed inequality and set the stage for other populations to get ahead. Soon after, they faced the implantation of thick, political roots that allowed racial disparities to continue to exist. Today, black Americans face major structural challenges that make the process of becoming a physician more challenging than it is for other populations. Though measures such as affirmative action have intervened to alleviate this excess difficulty, the social pressure, financial burden, and fear of exclusion (and racism) are a weight that these individuals continue to carry.
Medicine, at root, is an objective field, employing science and reproducible information to ensure that every individual – regardless of race, religion, color, creed, or sexual orientation – has the opportunity to thrive. However, the domain of this work is fundamentally dependent on the human domain – the physician patient relationship, the communication facilitated, and the vulnerability unlocked. By embedding a layer of diversity within the medical field, we can nourish every corner, fusing objective work with increased compassion and humanity. Not only will physicians be more empowered to stave off death, but they’ll experience powerful, visceral interactions that will resonate for a lifetime.